{
  "engine": {
    "id": "cpe-004",
    "code": "CPE-004",
    "name": "Iron Deficiency Pattern Engine",
    "version": "1.0.0",
    "url": "https://biod.ai/tools/iron",
    "status": "Executable specification v1.0.0, authored by Biod from the narrative CPE-004 specification and current guidelines. Reviewed by Dr. Vinicius Amaral, D.O. Not for clinical production use."
  },
  "notice": "Clinical decision support for licensed clinicians. Synthetic-data demonstration. Not FDA cleared. Physician adjudication required.",
  "rules": [
    {
      "id": "ID-SCOPE-01",
      "name": "Pediatric patients routed out",
      "group": "Scope and validity",
      "status": "active",
      "classification": "Priority 1",
      "summary": "Pediatric patients routed out. Evaluates age_years below 18.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "age_years < 18"
          ]
        },
        {
          "heading": "What it reports",
          "items": [
            "Routing: pediatric iron-deficiency pathway",
            "No adult classification is produced"
          ]
        },
        {
          "heading": "Diagnostic boundary",
          "items": [
            "Adult hemoglobin and ferritin thresholds do not apply to children."
          ]
        }
      ],
      "evidence": [
        "EV-WHO-HB-2011"
      ],
      "url": "https://biod.ai/tools/iron/rules/id-scope-01"
    },
    {
      "id": "ID-VAL-01",
      "name": "Inflammation changes how ferritin is read",
      "group": "Scope and validity",
      "status": "active",
      "classification": "Priority 2",
      "summary": "Inflammation changes how ferritin is read. Evaluates inflammation documented, OR hs-CRP above 5 mg/L.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "inflammation documented, OR hs-CRP above 5 mg/L"
          ]
        },
        {
          "heading": "What it reports",
          "items": [
            "Ferritin is an acute-phase reactant: a normal or high value no longer excludes iron deficiency",
            "Ferritin cutoffs shift (<70 ng/mL, WHO) and transferrin saturation is weighed alongside"
          ]
        },
        {
          "heading": "Diagnostic boundary",
          "items": [
            "Does not diagnose iron deficiency; it widens the question."
          ]
        }
      ],
      "evidence": [
        "EV-WHO-FERR-2020",
        "EV-AHA-HF-2022"
      ],
      "url": "https://biod.ai/tools/iron/rules/id-val-01"
    },
    {
      "id": "ID-VAL-02",
      "name": "Pregnancy context",
      "group": "Scope and validity",
      "status": "module",
      "classification": "Context",
      "summary": "Pregnancy context. Evaluates pregnant.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "pregnant"
          ]
        },
        {
          "heading": "What it reports",
          "items": [
            "Anemia threshold used: hemoglobin <11.0 g/dL",
            "Trimester-specific thresholds and management belong to the obstetric pathway"
          ]
        },
        {
          "heading": "Diagnostic boundary",
          "items": [
            "No supplementation advice is generated."
          ]
        }
      ],
      "evidence": [
        "EV-WHO-HB-2011",
        "EV-ACOG-ANEMIA-2021"
      ],
      "url": "https://biod.ai/tools/iron/rules/id-val-02"
    },
    {
      "id": "ID-ST-01",
      "name": "Iron stores depleted (ferritin below 15)",
      "group": "Iron status",
      "status": "active",
      "classification": "Priority 4",
      "summary": "Iron stores depleted (ferritin below 15). Evaluates ferritin below 15 ng/mL.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "ferritin < 15 ng/mL",
            "no inflammation or CRP elevation changing the cutoff"
          ]
        },
        {
          "heading": "What it reports",
          "items": [
            "Iron stores depleted: absolute iron deficiency criterion met (WHO)"
          ]
        },
        {
          "heading": "Recommended next steps (for physician review)",
          "items": [
            "Look for the cause: blood loss, diet, absorption and increased demand",
            "Complete iron studies and a CBC if not recent"
          ]
        },
        {
          "heading": "Diagnostic boundary",
          "items": [
            "A criterion for iron deficiency, not a statement about its cause."
          ]
        }
      ],
      "evidence": [
        "EV-WHO-FERR-2020",
        "EV-CAMASCHELLA-2015"
      ],
      "url": "https://biod.ai/tools/iron/rules/id-st-01"
    },
    {
      "id": "ID-ST-02",
      "name": "Low ferritin (15 to 29)",
      "group": "Iron status",
      "status": "active",
      "classification": "Priority 4",
      "summary": "Low ferritin (15 to 29). Evaluates ferritin 15 to 29 ng/mL.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "ferritin 15 to 29 ng/mL",
            "no inflammation changing the cutoff"
          ]
        },
        {
          "heading": "What it reports",
          "items": [
            "Low ferritin: iron deficiency likely in the right context",
            "Below the 30 ng/mL level many guidelines use, even when the lab flags it as normal"
          ]
        },
        {
          "heading": "Diagnostic boundary",
          "items": [
            "Interpret with symptoms, hemoglobin and transferrin saturation."
          ]
        }
      ],
      "evidence": [
        "EV-WHO-FERR-2020",
        "EV-ACOG-ANEMIA-2021",
        "EV-AGA-2020"
      ],
      "url": "https://biod.ai/tools/iron/rules/id-st-02"
    },
    {
      "id": "ID-ST-03",
      "name": "Borderline ferritin (30 to 44)",
      "group": "Iron status",
      "status": "active",
      "classification": "Priority 5",
      "summary": "Borderline ferritin (30 to 44). Evaluates ferritin 30 to 44 ng/mL.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "ferritin 30 to 44 ng/mL",
            "anemia present OR iron-related symptoms OR restless legs"
          ]
        },
        {
          "heading": "What it reports",
          "items": [
            "Borderline ferritin: the AGA 2020 diagnostic cutoff for iron-deficiency anemia is 45 ng/mL"
          ]
        },
        {
          "heading": "Diagnostic boundary",
          "items": [
            "Not on its own an iron-deficiency criterion in an asymptomatic non-anemic patient."
          ]
        }
      ],
      "evidence": [
        "EV-AGA-2020"
      ],
      "url": "https://biod.ai/tools/iron/rules/id-st-03"
    },
    {
      "id": "ID-ST-04",
      "name": "Iron deficiency likely despite inflammation",
      "group": "Iron status",
      "status": "active",
      "classification": "Priority 4",
      "summary": "Iron deficiency likely despite inflammation. Evaluates inflammation documented or hs-CRP above 5 mg/L.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "inflammation documented or hs-CRP above 5 mg/L",
            "ferritin < 70 ng/mL"
          ]
        },
        {
          "heading": "Supportive, not required",
          "items": [
            "transferrin saturation < 20%"
          ]
        },
        {
          "heading": "What it reports",
          "items": [
            "Iron deficiency likely coexisting with inflammation"
          ]
        },
        {
          "heading": "Diagnostic boundary",
          "items": [
            "Ferritin is partly raised by inflammation, so the cutoff is higher than without it."
          ]
        }
      ],
      "evidence": [
        "EV-WHO-FERR-2020"
      ],
      "url": "https://biod.ai/tools/iron/rules/id-st-04"
    },
    {
      "id": "ID-ST-05",
      "name": "Inflammation-associated iron restriction possible",
      "group": "Iron status",
      "status": "active",
      "classification": "Priority 5",
      "summary": "Inflammation-associated iron restriction possible. Evaluates inflammation documented or hs-CRP above 5 mg/L.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "inflammation documented or hs-CRP above 5 mg/L",
            "ferritin 70 to 299 ng/mL",
            "transferrin saturation < 20%"
          ]
        },
        {
          "heading": "What it reports",
          "items": [
            "Functional iron restriction possible: anemia of inflammation, with or without absolute deficiency"
          ]
        },
        {
          "heading": "Diagnostic boundary",
          "items": [
            "Cannot separate anemia of inflammation from combined deficiency by these values alone."
          ]
        }
      ],
      "evidence": [
        "EV-AHA-HF-2022",
        "EV-CAMASCHELLA-2015"
      ],
      "url": "https://biod.ai/tools/iron/rules/id-st-05"
    },
    {
      "id": "ID-ST-06",
      "name": "Heart-failure iron deficiency criterion",
      "group": "Iron status",
      "status": "active",
      "classification": "Priority 3",
      "summary": "Heart-failure iron deficiency criterion. Evaluates heart failure documented.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "heart failure documented",
            "ferritin < 100 ng/mL, OR ferritin 100 to 299 ng/mL with transferrin saturation < 20%"
          ]
        },
        {
          "heading": "What it reports",
          "items": [
            "Iron deficiency by the AHA/ACC/HFSA heart-failure definition, with or without anemia"
          ]
        },
        {
          "heading": "Recommended next steps (for physician review)",
          "items": [
            "Physician to review the heart-failure iron-repletion pathway"
          ]
        },
        {
          "heading": "Diagnostic boundary",
          "items": [
            "Definition applies to heart failure; it is not a general iron-deficiency cutoff."
          ]
        }
      ],
      "evidence": [
        "EV-AHA-HF-2022"
      ],
      "url": "https://biod.ai/tools/iron/rules/id-st-06"
    },
    {
      "id": "ID-AN-01",
      "name": "Anemia present by WHO thresholds",
      "group": "Anemia",
      "status": "active",
      "classification": "Priority 4",
      "summary": "Anemia present by WHO thresholds. Evaluates hemoglobin below 13.0 g/dL (men).",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "hemoglobin < 13.0 g/dL (men)",
            "hemoglobin < 12.0 g/dL (non-pregnant women)",
            "hemoglobin < 11.0 g/dL (pregnancy)"
          ]
        },
        {
          "heading": "What it reports",
          "items": [
            "Anemia by WHO hemoglobin thresholds"
          ]
        },
        {
          "heading": "Diagnostic boundary",
          "items": [
            "Anemia is a finding, not a cause."
          ]
        }
      ],
      "evidence": [
        "EV-WHO-HB-2011"
      ],
      "url": "https://biod.ai/tools/iron/rules/id-an-01"
    },
    {
      "id": "ID-11",
      "name": "Iron-deficiency anemia pattern",
      "group": "Anemia",
      "status": "active",
      "classification": "Priority 3",
      "summary": "Iron-deficiency anemia pattern. Evaluates anemia present (ID-AN-01).",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "anemia present (ID-AN-01)",
            "an iron-deficiency criterion met (ID-ST-01, ID-ST-02, ID-ST-04 or ID-ST-06)"
          ]
        },
        {
          "heading": "Supportive, not required",
          "items": [
            "MCV < 80 fL",
            "MCH < 27 pg",
            "RDW > 14.5%",
            "transferrin saturation < 16%"
          ]
        },
        {
          "heading": "What it reports",
          "items": [
            "Biochemical pattern compatible with iron-deficiency anemia (stage 3)"
          ]
        },
        {
          "heading": "Recommended next steps (for physician review)",
          "items": [
            "Establish the source: menstrual loss, gastrointestinal loss, diet or malabsorption"
          ]
        },
        {
          "heading": "Never outputs",
          "items": [
            "a product, dose or duration of iron therapy"
          ]
        },
        {
          "heading": "Diagnostic boundary",
          "items": [
            "A pattern for physician review; the cause still has to be found."
          ]
        }
      ],
      "evidence": [
        "EV-CAMASCHELLA-2015",
        "EV-LOPEZ-2016",
        "EV-WHO-FERR-2020"
      ],
      "url": "https://biod.ai/tools/iron/rules/id-11"
    },
    {
      "id": "ID-12",
      "name": "Iron deficiency without anemia",
      "group": "Anemia",
      "status": "active",
      "classification": "Priority 4",
      "summary": "Iron deficiency without anemia. Evaluates no anemia.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "no anemia",
            "an iron-deficiency criterion met (ID-ST-01, ID-ST-02, ID-ST-04 or ID-ST-06)"
          ]
        },
        {
          "heading": "What it reports",
          "items": [
            "Biochemical pattern compatible with iron deficiency without anemia (stage 1 or 2)"
          ]
        },
        {
          "heading": "Diagnostic boundary",
          "items": [
            "A normal CBC does not exclude it. Symptoms such as fatigue are non-specific and are not attributed to iron by this rule."
          ]
        }
      ],
      "evidence": [
        "EV-CAMASCHELLA-2015",
        "EV-LOPEZ-2016"
      ],
      "url": "https://biod.ai/tools/iron/rules/id-12"
    },
    {
      "id": "ID-13",
      "name": "Iron-deficient erythropoiesis",
      "group": "Anemia",
      "status": "active",
      "classification": "Priority 5",
      "summary": "Iron-deficient erythropoiesis. Evaluates no anemia.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "no anemia",
            "transferrin saturation < 20% OR reticulocyte hemoglobin < 28 pg",
            "an iron-deficiency criterion met"
          ]
        },
        {
          "heading": "What it reports",
          "items": [
            "Stage 2: iron supply to the marrow is becoming limiting before hemoglobin falls"
          ]
        },
        {
          "heading": "Diagnostic boundary",
          "items": [
            "Reticulocyte hemoglobin cutoffs are assay-specific."
          ]
        }
      ],
      "evidence": [
        "EV-CAMASCHELLA-2015"
      ],
      "url": "https://biod.ai/tools/iron/rules/id-13"
    },
    {
      "id": "ID-14",
      "name": "Microcytic anemia differential",
      "group": "Anemia",
      "status": "active",
      "classification": "Priority 4",
      "summary": "Microcytic anemia differential. Evaluates anemia present.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "anemia present",
            "MCV < 80 fL"
          ]
        },
        {
          "heading": "What it reports",
          "items": [
            "Iron deficiency, anemia of inflammation, thalassemia trait and sideroblastic anemia are compared on ferritin, transferrin saturation, RDW and the Mentzer index (MCV ÷ RBC)"
          ]
        },
        {
          "heading": "Recommended next steps (for physician review)",
          "items": [
            "If the Mentzer index is below 13 and iron indices are not deficient, consider hemoglobin electrophoresis"
          ]
        },
        {
          "heading": "Diagnostic boundary",
          "items": [
            "The Mentzer index screens; it does not establish thalassemia."
          ]
        }
      ],
      "evidence": [
        "EV-MENTZER-1973",
        "EV-CAMASCHELLA-2015"
      ],
      "url": "https://biod.ai/tools/iron/rules/id-14"
    },
    {
      "id": "ID-OV-01",
      "name": "Iron-overload pattern",
      "group": "Iron overload",
      "status": "active",
      "classification": "Priority 3",
      "summary": "Iron-overload pattern. Evaluates transferrin saturation above 45%.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "transferrin saturation > 45%",
            "ferritin > 300 ng/mL (men) or > 200 ng/mL (women)"
          ]
        },
        {
          "heading": "What it reports",
          "items": [
            "Pattern that raises the possibility of iron overload"
          ]
        },
        {
          "heading": "Recommended next steps (for physician review)",
          "items": [
            "Repeat on a fasting morning sample",
            "Physician to consider HFE genotyping per EASL 2022",
            "Consider liver, diabetes and heart involvement"
          ]
        },
        {
          "heading": "Diagnostic boundary",
          "items": [
            "Not a diagnosis of hemochromatosis."
          ]
        }
      ],
      "evidence": [
        "EV-EASL-HFE-2022"
      ],
      "url": "https://biod.ai/tools/iron/rules/id-ov-01"
    },
    {
      "id": "ID-OV-02",
      "name": "Very high ferritin",
      "group": "Iron overload",
      "status": "active",
      "classification": "Priority 2",
      "summary": "Very high ferritin. Evaluates ferritin above 1000 ng/mL.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "ferritin > 1000 ng/mL"
          ]
        },
        {
          "heading": "What it reports",
          "items": [
            "Priority review: very high ferritin has several serious causes"
          ]
        },
        {
          "heading": "Recommended next steps (for physician review)",
          "items": [
            "Consider iron overload, hepatocellular injury, hemolysis, malignancy, macrophage activation and inflammation"
          ]
        },
        {
          "heading": "Diagnostic boundary",
          "items": [
            "Ferritin alone does not identify the cause."
          ]
        }
      ],
      "evidence": [
        "EV-EASL-HFE-2022"
      ],
      "url": "https://biod.ai/tools/iron/rules/id-ov-02"
    },
    {
      "id": "ID-SAFE-01",
      "name": "Severe anemia",
      "group": "Safety",
      "status": "active",
      "classification": "Priority 1",
      "summary": "Severe anemia. Evaluates hemoglobin below 7.0 g/dL, OR hemoglobin below 8.0 g/dL with chest pain, dyspnea at rest or syncope.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "hemoglobin < 7.0 g/dL, OR hemoglobin < 8.0 g/dL with chest pain, dyspnea at rest or syncope"
          ]
        },
        {
          "heading": "What it reports",
          "items": [
            "Urgent clinical assessment: severe anemia"
          ]
        },
        {
          "heading": "Diagnostic boundary",
          "items": [
            "Treatment decisions, including transfusion, belong to the treating physician."
          ]
        }
      ],
      "evidence": [
        "EV-WHO-HB-2011"
      ],
      "url": "https://biod.ai/tools/iron/rules/id-safe-01"
    },
    {
      "id": "ID-SAFE-02",
      "name": "Overt gastrointestinal bleeding signs",
      "group": "Safety",
      "status": "active",
      "classification": "Priority 1",
      "summary": "Overt gastrointestinal bleeding signs. Evaluates melena OR hematochezia OR hematemesis documented.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "melena OR hematochezia OR hematemesis documented",
            "anemia or iron deficiency present"
          ]
        },
        {
          "heading": "What it reports",
          "items": [
            "Urgent clinical assessment: possible active gastrointestinal bleeding"
          ]
        },
        {
          "heading": "Diagnostic boundary",
          "items": [
            "Routine outpatient iron-deficiency pathway is not appropriate."
          ]
        }
      ],
      "evidence": [
        "EV-AGA-2020"
      ],
      "url": "https://biod.ai/tools/iron/rules/id-safe-02"
    },
    {
      "id": "ID-GI-01",
      "name": "Gastrointestinal evaluation: men and postmenopausal women",
      "group": "Safety",
      "status": "active",
      "classification": "Priority 2",
      "summary": "Gastrointestinal evaluation: men and postmenopausal women. Evaluates iron-deficiency anemia pattern (ID-11).",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "iron-deficiency anemia pattern (ID-11)",
            "male, OR postmenopausal woman"
          ]
        },
        {
          "heading": "What it reports",
          "items": [
            "Priority review: iron-deficiency anemia in a man or postmenopausal woman needs a gastrointestinal source considered"
          ]
        },
        {
          "heading": "Recommended next steps (for physician review)",
          "items": [
            "AGA 2020: bidirectional endoscopy is suggested for asymptomatic men and postmenopausal women with iron-deficiency anemia",
            "Colorectal cancer screening status should be reviewed"
          ]
        },
        {
          "heading": "Diagnostic boundary",
          "items": [
            "Physician decides the evaluation; the engine does not choose the test."
          ]
        }
      ],
      "evidence": [
        "EV-AGA-2020"
      ],
      "url": "https://biod.ai/tools/iron/rules/id-gi-01"
    },
    {
      "id": "ID-GI-02",
      "name": "Premenopausal women: blood-loss assessment",
      "group": "Safety",
      "status": "active",
      "classification": "Priority 3",
      "summary": "Premenopausal women: blood-loss assessment. Evaluates iron-deficiency anemia pattern (ID-11).",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "iron-deficiency anemia pattern (ID-11)",
            "premenopausal woman"
          ]
        },
        {
          "heading": "What it reports",
          "items": [
            "Menstrual blood loss should be quantified; gastrointestinal causes remain possible"
          ]
        },
        {
          "heading": "Recommended next steps (for physician review)",
          "items": [
            "Assess menstrual history and heavy menstrual bleeding",
            "Consider noninvasive celiac and H. pylori testing or endoscopy when there is no explanation, GI symptoms or poor response"
          ]
        },
        {
          "heading": "Diagnostic boundary",
          "items": [
            "Heavy menstrual bleeding does not exclude a gastrointestinal source."
          ]
        }
      ],
      "evidence": [
        "EV-AGA-2020"
      ],
      "url": "https://biod.ai/tools/iron/rules/id-gi-02"
    },
    {
      "id": "ID-CEL-01",
      "name": "Celiac and H. pylori consideration",
      "group": "Safety",
      "status": "active",
      "classification": "Priority 3",
      "summary": "Celiac and H. pylori consideration. Evaluates iron-deficiency anemia pattern, OR iron deficiency not responding to oral iron.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "iron-deficiency anemia pattern, OR iron deficiency not responding to oral iron",
            "celiac serology not documented"
          ]
        },
        {
          "heading": "What it reports",
          "items": [
            "Consider celiac serology (tissue transglutaminase IgA with total IgA) and H. pylori testing"
          ]
        },
        {
          "heading": "Diagnostic boundary",
          "items": [
            "Malabsorption is one cause among several."
          ]
        }
      ],
      "evidence": [
        "EV-AGA-2020",
        "EV-ACG-CELIAC-2023"
      ],
      "url": "https://biod.ai/tools/iron/rules/id-cel-01"
    },
    {
      "id": "ID-REF-01",
      "name": "Iron deficiency not responding to oral iron",
      "group": "Safety",
      "status": "active",
      "classification": "Priority 3",
      "summary": "Iron deficiency not responding to oral iron. Evaluates oral iron taken for at least 3 months with adherence documented.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "oral iron taken for at least 3 months with adherence documented",
            "iron deficiency still present"
          ]
        },
        {
          "heading": "What it reports",
          "items": [
            "Refractory pattern: reconsider adherence, ongoing loss, malabsorption and the diagnosis"
          ]
        },
        {
          "heading": "Recommended next steps (for physician review)",
          "items": [
            "Review ongoing blood loss and malabsorption (celiac disease, H. pylori, atrophic gastritis, surgery, long-term acid suppression)",
            "Physician to consider whether another route is appropriate"
          ]
        },
        {
          "heading": "Diagnostic boundary",
          "items": [
            "No route or dose is recommended."
          ]
        }
      ],
      "evidence": [
        "EV-AGA-2020",
        "EV-CAMASCHELLA-2015"
      ],
      "url": "https://biod.ai/tools/iron/rules/id-ref-01"
    },
    {
      "id": "ID-HF-01",
      "name": "Heart failure without iron studies",
      "group": "Context triggers",
      "status": "active",
      "classification": "Priority 4",
      "summary": "Heart failure without iron studies. Evaluates heart failure documented.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "heart failure documented",
            "ferritin or transferrin saturation not available"
          ]
        },
        {
          "heading": "What it reports",
          "items": [
            "Iron status is not assessed in a patient with heart failure"
          ]
        },
        {
          "heading": "Recommended next steps (for physician review)",
          "items": [
            "Consider ferritin and transferrin saturation: iron deficiency is common in heart failure and has a guideline definition"
          ]
        },
        {
          "heading": "Diagnostic boundary",
          "items": [
            "A prompt to measure, not a diagnosis."
          ]
        }
      ],
      "evidence": [
        "EV-AHA-HF-2022"
      ],
      "url": "https://biod.ai/tools/iron/rules/id-hf-01"
    },
    {
      "id": "ID-CKD-01",
      "name": "Chronic kidney disease with anemia",
      "group": "Context triggers",
      "status": "active",
      "classification": "Priority 4",
      "summary": "Chronic kidney disease with anemia. Evaluates CKD documented.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "CKD documented",
            "anemia present"
          ]
        },
        {
          "heading": "What it reports",
          "items": [
            "Iron indices should be assessed before an erythropoiesis-stimulating agent is considered",
            "KDIGO 2012 suggests a trial of iron when transferrin saturation ≤30% and ferritin ≤500 ng/mL in anemic CKD patients not on iron"
          ]
        },
        {
          "heading": "Diagnostic boundary",
          "items": [
            "ESA and iron decisions belong to the treating physician or nephrologist."
          ]
        }
      ],
      "evidence": [
        "EV-KDIGO-ANEMIA-2012"
      ],
      "url": "https://biod.ai/tools/iron/rules/id-ckd-01"
    },
    {
      "id": "ID-RLS-01",
      "name": "Restless legs and iron status",
      "group": "Context triggers",
      "status": "active",
      "classification": "Priority 5",
      "summary": "Restless legs and iron status. Evaluates restless legs symptoms documented.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "restless legs symptoms documented",
            "ferritin ≤ 75 ng/mL OR transferrin saturation < 20% OR ferritin not measured"
          ]
        },
        {
          "heading": "What it reports",
          "items": [
            "Iron status is relevant to restless legs: the IRLSSG uses ferritin ≤75 ng/mL and transferrin saturation <20% as the threshold to consider iron"
          ]
        },
        {
          "heading": "Diagnostic boundary",
          "items": [
            "Does not diagnose restless legs syndrome or attribute it to iron."
          ]
        }
      ],
      "evidence": [
        "EV-IRLSSG-2018"
      ],
      "url": "https://biod.ai/tools/iron/rules/id-rls-01"
    },
    {
      "id": "ID-HAIR-01",
      "name": "Diffuse hair loss and ferritin",
      "group": "Context triggers",
      "status": "active",
      "classification": "Priority 6",
      "summary": "Diffuse hair loss and ferritin. Evaluates diffuse hair loss documented.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "diffuse hair loss documented",
            "ferritin not measured OR ferritin < 40 ng/mL"
          ]
        },
        {
          "heading": "What it reports",
          "items": [
            "Ferritin is part of the evaluation of diffuse hair loss; low values may contribute"
          ]
        },
        {
          "heading": "Diagnostic boundary",
          "items": [
            "Iron deficiency is one of several causes (thyroid disease, medications, nutritional and other); a ferritin target is not set by this rule."
          ]
        }
      ],
      "evidence": [
        "EV-TROST-2006"
      ],
      "url": "https://biod.ai/tools/iron/rules/id-hair-01"
    },
    {
      "id": "ID-PICA-01",
      "name": "Pica or pagophagia",
      "group": "Context triggers",
      "status": "active",
      "classification": "Priority 5",
      "summary": "Pica or pagophagia. Evaluates pica OR pagophagia (ice craving) documented.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "pica OR pagophagia (ice craving) documented"
          ]
        },
        {
          "heading": "What it reports",
          "items": [
            "Pica is associated with iron deficiency: iron studies are reasonable if not recent"
          ]
        },
        {
          "heading": "Diagnostic boundary",
          "items": [
            "No sensitivity or specificity is claimed."
          ]
        }
      ],
      "evidence": [
        "EV-CAMASCHELLA-2015"
      ],
      "url": "https://biod.ai/tools/iron/rules/id-pica-01"
    },
    {
      "id": "ID-RISK-01",
      "name": "High-risk group without recent iron studies",
      "group": "Context triggers",
      "status": "active",
      "classification": "Priority 6",
      "summary": "High-risk group without recent iron studies. Evaluates any of: heavy menstrual bleeding, vegetarian or vegan diet, endurance athlete, frequent blood donor, bariatric surgery, celiac or inflammatory bowel disease, acid suppression for more than 6 months, pregnancy.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "any of: heavy menstrual bleeding, vegetarian or vegan diet, endurance athlete, frequent blood donor, bariatric surgery, celiac or inflammatory bowel disease, acid suppression for more than 6 months, pregnancy",
            "ferritin not available"
          ]
        },
        {
          "heading": "What it reports",
          "items": [
            "Screening opportunity: a group at higher risk of iron deficiency has no ferritin on file"
          ]
        },
        {
          "heading": "Diagnostic boundary",
          "items": [
            "Groups raise the pre-test likelihood; they are not findings."
          ]
        }
      ],
      "evidence": [
        "EV-CAMASCHELLA-2015",
        "EV-LOPEZ-2016"
      ],
      "url": "https://biod.ai/tools/iron/rules/id-risk-01"
    },
    {
      "id": "ID-IV-01",
      "name": "Intravenous iron under consideration with active infection",
      "group": "Context triggers",
      "status": "active",
      "classification": "Priority 3",
      "summary": "Intravenous iron under consideration with active infection. Evaluates intravenous iron under consideration.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "intravenous iron under consideration",
            "active infection documented"
          ]
        },
        {
          "heading": "What it reports",
          "items": [
            "Caution flag: review product labeling and local guidance on intravenous iron during active infection"
          ]
        },
        {
          "heading": "Diagnostic boundary",
          "items": [
            "A review prompt, not a contraindication. The engine does not recommend intravenous iron."
          ]
        }
      ],
      "evidence": [
        "EV-IV-LABEL"
      ],
      "url": "https://biod.ai/tools/iron/rules/id-iv-01"
    },
    {
      "id": "ID-CALC-01",
      "name": "Derived values",
      "group": "Calculations",
      "status": "module",
      "classification": "Context",
      "summary": "Derived values. Evaluates serum iron and TIBC available → transferrin saturation.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "serum iron and TIBC available → transferrin saturation",
            "MCV and RBC count available → Mentzer index"
          ]
        },
        {
          "heading": "What it reports",
          "items": [
            "Transferrin saturation = serum iron ÷ TIBC × 100",
            "Mentzer index = MCV ÷ RBC count (10¹²/L)"
          ]
        },
        {
          "heading": "Diagnostic boundary",
          "items": [
            "Informational calculations."
          ]
        }
      ],
      "evidence": [
        "EV-MENTZER-1973"
      ],
      "url": "https://biod.ai/tools/iron/rules/id-calc-01"
    },
    {
      "id": "ID-MISS-01",
      "name": "Core iron studies missing",
      "group": "Missing data",
      "status": "active",
      "classification": "Priority 8",
      "summary": "Core iron studies missing. Evaluates ferritin missing.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "ferritin missing",
            "OR transferrin saturation missing while inflammation, heart failure or CKD is present"
          ]
        },
        {
          "heading": "What it reports",
          "items": [
            "Iron status cannot be classified with the data entered"
          ]
        },
        {
          "heading": "Diagnostic boundary",
          "items": [
            "Names what is needed; never infers a value."
          ]
        }
      ],
      "evidence": [
        "EV-WHO-FERR-2020"
      ],
      "url": "https://biod.ai/tools/iron/rules/id-miss-01"
    }
  ],
  "evidence": [
    {
      "id": "EV-WHO-FERR-2020",
      "citation": "World Health Organization. WHO guideline on use of ferritin concentrations to assess iron status in individuals and populations. Geneva: WHO; 2020.",
      "supports": [
        "Ferritin below 15 µg/L indicates iron deficiency in healthy adults",
        "A higher cutoff (<70 µg/L) applies in the presence of infection or inflammation"
      ]
    },
    {
      "id": "EV-WHO-HB-2011",
      "citation": "World Health Organization. Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. Geneva: WHO; 2011.",
      "supports": [
        "Anemia thresholds: hemoglobin <13.0 g/dL (men), <12.0 g/dL (non-pregnant women), <11.0 g/dL (pregnancy)"
      ]
    },
    {
      "id": "EV-AGA-2020",
      "citation": "Ko CW, Siddique SM, Patel A, et al. AGA Clinical Practice Guidelines on the Gastrointestinal Evaluation of Iron Deficiency Anemia. Gastroenterology. 2020;159(3):1085-1094.",
      "supports": [
        "A ferritin cutoff of 45 ng/mL is suggested to diagnose iron deficiency",
        "Bidirectional endoscopy is suggested for asymptomatic men and postmenopausal women with iron-deficiency anemia",
        "Celiac serology and H. pylori testing have a role in evaluation"
      ]
    },
    {
      "id": "EV-CAMASCHELLA-2015",
      "citation": "Camaschella C. Iron-deficiency anemia. N Engl J Med. 2015;372(19):1832-1843.",
      "supports": [
        "Stages of iron deficiency, causes and differential diagnosis of microcytic anemia"
      ]
    },
    {
      "id": "EV-LOPEZ-2016",
      "citation": "Lopez A, Cacoub P, Macdougall IC, Peyrin-Biroulet L. Iron deficiency anaemia. Lancet. 2016;387(10021):907-916.",
      "supports": [
        "Risk groups, causes and evaluation of iron deficiency anemia"
      ]
    },
    {
      "id": "EV-AHA-HF-2022",
      "citation": "Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. Circulation. 2022;145(18):e895-e1032.",
      "supports": [
        "Iron deficiency in heart failure: ferritin <100 ng/mL, or 100–299 ng/mL with transferrin saturation <20%"
      ]
    },
    {
      "id": "EV-KDIGO-ANEMIA-2012",
      "citation": "KDIGO Anemia Work Group. KDIGO Clinical Practice Guideline for Anemia in Chronic Kidney Disease. Kidney Int Suppl. 2012;2(4):279-335.",
      "supports": [
        "Assess iron status before ESA therapy",
        "Iron trial in anemic CKD with transferrin saturation ≤30% and ferritin ≤500 ng/mL"
      ]
    },
    {
      "id": "EV-IRLSSG-2018",
      "citation": "Allen RP, Picchietti DL, Auerbach M, et al. Evidence-based and consensus clinical practice guidelines for the iron treatment of restless legs syndrome/Willis-Ekbom disease in adults and children. Sleep Med. 2018;41:27-44.",
      "supports": [
        "Consider iron when ferritin is ≤75 µg/L or transferrin saturation is <20%"
      ]
    },
    {
      "id": "EV-ACG-CELIAC-2023",
      "citation": "Rubio-Tapia A, Hill ID, Semrad C, et al. American College of Gastroenterology Guidelines Update: Diagnosis and Management of Celiac Disease. Am J Gastroenterol. 2023;118(1):59-76.",
      "supports": [
        "Celiac serology is appropriate in unexplained iron-deficiency anemia"
      ]
    },
    {
      "id": "EV-EASL-HFE-2022",
      "citation": "European Association for the Study of the Liver. EASL Clinical Practice Guidelines on haemochromatosis. J Hepatol. 2022;77(2):479-502.",
      "supports": [
        "Transferrin saturation >45% as the first-line screen",
        "Ferritin above 200 µg/L (women) or 300 µg/L (men) with raised saturation prompts HFE testing"
      ]
    },
    {
      "id": "EV-ACOG-ANEMIA-2021",
      "citation": "American College of Obstetricians and Gynecologists. Anemia in Pregnancy. ACOG Practice Bulletin No. 233. Obstet Gynecol. 2021;138(2):e55-e64.",
      "supports": [
        "Pregnancy anemia thresholds; ferritin below 30 ng/mL suggests iron deficiency in pregnancy"
      ]
    },
    {
      "id": "EV-TROST-2006",
      "citation": "Trost LB, Bergfeld WF, Calogeras E. The diagnosis and treatment of iron deficiency and its potential relationship to hair loss. J Am Acad Dermatol. 2006;54(5):824-844.",
      "supports": [
        "Iron deficiency may contribute to diffuse hair loss; ferritin is part of the evaluation"
      ]
    },
    {
      "id": "EV-MENTZER-1973",
      "citation": "Mentzer WC Jr. Differentiation of iron deficiency from thalassaemia trait. Lancet. 1973;1(7808):882.",
      "supports": [
        "MCV ÷ RBC count below 13 favors thalassemia trait; above 13 favors iron deficiency"
      ]
    },
    {
      "id": "EV-IV-LABEL",
      "citation": "U.S. Food and Drug Administration. Prescribing information for the specific intravenous iron product (verify current labeling).",
      "supports": [
        "Product-specific warnings, including hypersensitivity and infection precautions"
      ]
    }
  ]
}